Traffic Convictions and Forfeitures for the Past 3 Years (Other Than Parking Violations)

Dates Convicted (month/year)

Violation

State of Violation Location

Penalty (forfeited bond, collateral and/or points)

1

2

3

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?

Yes No

If yes, explain

B. Has any license, permit or privilege ever been suspended or revoked?

Yes No

If yes, explain

Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior tothe initial three years (total of ten years employment record).

Must list the complete mailing address: street number and name, city, state and zip code.

Last Employer Name

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Position Held

From

-
Month
-
Day Year

To

-
Month
-
Day Year

Salary

Reasons for Leaving

Any Gaps in Employment and/or Unemployment Must be Explained. Include Dates (Month/Year) and Reason

Were you subject to the Federal Motor Carrier Safety Regulations {FMCSRs) while employed by the previous employer?

Yes No

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?

Yes No

Second Last Employer Name

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Position Held

From

-
Month
-
Day Year

To

-
Month
-
Day Year

Salary

Reasons for Leaving

Any Gaps in Employment and/or Unemployment Must be Explained. Include Dates (Month/Year) and Reason

Were you subject to the Federal Motor Carrier Safety Regulations {FMCSRs) while employed by the previous employer?

Yes No

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?

Yes No

Third Last Employer Name

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Position Held

From

-
Month
-
Day Year

To

-
Month
-
Day Year

Salary

Reasons for Leaving

Any Gaps in Employment and/or Unemployment Must be Explained. Include Dates (Month/Year) and Reason

Were you subject to the Federal Motor Carrier Safety Regulations {FMCSRs) while employed by the previous employer?

Yes No

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?

Yes No

TO BE READ AND CONFIRMED BY APPLICANT

I authorize you to make sure investigations and inquiries to my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, healthcare providers and other persons from all liability in responding to inquiries and releasing information in connection with my application.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result indischarge. I understand, also, that I am required to abide by all rules and regulations of the Company.

"I understand that information I provide regarding current and/or previous employers may be used, and those employer{s) will becontacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). 1 understand that 1have the right to:

• Review information provided by current/previous employers;

• Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected informationto the prospective employer; and

• Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on theaccuracy of the information."

Yes No

This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of myknowledge.

Yes No

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Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.